Healthcare Provider Details

I. General information

NPI: 1881765584
Provider Name (Legal Business Name): THOMAS L JOHNSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 S SEPULVEDA BLVD STE 121
LOS ANGELES CA
90045-4849
US

IV. Provider business mailing address

9100 S SEPULVEDA BLVD STE 121
LOS ANGELES CA
90045-4849
US

V. Phone/Fax

Practice location:
  • Phone: 310-674-6785
  • Fax: 310-674-2161
Mailing address:
  • Phone: 310-674-6785
  • Fax: 310-674-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC41044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: